History

During the initial evaluation of the patient, the physician should establish the ED as a safe space for the patient. Simple actions such as knocking and asking permission to enter the room may provide reassurance to the patient that their preferences will be taken into consideration. Clinicians should confirm the pronunciation of the patient’s name, use their preferred pronouns, and use an interpreter, if necessary. Ask whether the patient wants others (friends or family members) in the room during the history and examination. The patient may not feel empowered to ask visitors to leave, so this should be addressed by the clinician. Conversely, the patient may feel safer with friends or family members present in the room or on speaker phone.

Physical Examination

Clinicians should describe the steps of the physical examination so that the patient knows what to expect and should ask for consent to do the examination, especially of sensitive areas of the body. Stress to the patient that they can refuse any or all parts of the medical forensic examination. The patient should be offered as much privacy as possible during the examination. This may mean moving a patient from a hallway bed into an examination room or using adequate draping techniques. The clinician should also ask questions such as, “Is there a part of the examination that is worrisome to you? Is there anything we can do to make you more comfortable?”

Procedures

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Procedures, including necessary equipment, should be explained in as much detail as the patient would like. After obtaining consent, the clinician should provide as much pain relief as possible prior to the procedure. Ask the patient about preferences regarding position of comfort and whether they want a support person present. Give the patient as much control as possible. The speculum or pelvic exam can be triggering to a patient with a past history of sexual abuse or assault; therefore, patients may prefer to self-insert a speculum or to self-swab the genitals. If the patient needs a break during the procedure, this should be provided if possible.

Disposition

Shared decision making is key to empowering patients in their own medical care. If the patient is being discharged, ensure appropriate referral and community resources. Because many ED patients are experiencing stress, which may interfere with comprehension and retention of instructions, methods such as teach-back should be used. Patients should be asked what questions they have, and resources should be provided in case they have questions following disposition.